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What Massachusetts can do in an ACA-altered world

By Josh Archambault

Updated:
05/24/2017 08:41:11 AM EDT

The effort to repeal and replace the Affordable Care Act has sprung back to life. Thoughtful reform could lower the commonwealth's highest-in-the-nation premiums, but it will require a willingness to re-examine decades-old local assumptions.

If the ACA is repealed and replaced, Massachusetts shouldn't default to the status quo ante. Coverage rates did increase under "RomneyCare," but premiums remained the nation's most expensive, emergency room utilization stayed high, and wait times to see a doctor may have gotten longer. Care for the uninsured still cost more than $500 million annually, and the promise of redirecting billions in supplemental hospital payments to underwrite the program never fully materialized.

In addition, MassHealth (Medicaid) has expanded rapidly, with Massachusetts starting to resemble West Virginia in terms of percentage of residents on Medicaid. Today, roughly one in four residents receive MassHealth benefits, costing the commonwealth over $16 billion annually. At roughly 40 percent of the total state budget, it crowds out investments in education, the opioid crisis or transportation.

Even more important is quality of care. Why do studies show health outcomes for Medicaid recipients are mixed?

The commonwealth's obsessive focus on coverage and damn-the-costs attitude is a textbook example of missing the forest for the trees.

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What good is insurance if you can't find a doctor?

On a per capita basis, Massachusetts has the most doctors of any state, yet Medicaid recipients often struggle to access them. Surveys have found that at times only 50-60 percent of internal medicine and 60-70 percent of family medicine offices accept Medicaid patients, compared to more than 85 percent of those with Medicare or private insurance. If our goal is access to care, not just coverage, we must move individuals from Medicaid to private insurance.

To reduce premiums the commonwealth must question long-held nostrums. Currently, strict insurance market regulation results in high premiums that are affordable only to those with generous government subsidies or employer assistance.

Then there's the Connector. If federal changes make tax credits available for buying private insurance, the Connector's structure must change, or it may even have to be phased out.

Massachusetts should also learn from other states. Before the ACA ended it, Maine ran a very effective program that helped those with pre-existing conditions, even as it decreased premiums for everyone buying insurance on their own -- by approximately half for older adults and up to 70 percent for the young. Individuals with pre-existing conditions enrolled in the same plan at the same rates as everyone else.

Finally, Massachusetts needs to get serious about transparency. The Group Insurance Commission, which insures state and local employees and their families, is running a pilot program that pays patients to shop for high-quality, low-cost providers. A similar program has saved New Hampshire over $12 million and resulted in patients receiving over $1.2 million in incentive payments. These kinds of programs should be available to all.

Massachusetts must be ready not just to be reactive, but to react intelligently to any changes in D.C. We must get smarter about tackling health care costs and realize that coverage and cost are two sides of the same coin.

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